Race and Medicine

Race and Medicine

Issue: November 2020
Disclosures: Dowell reports being on the speakers' bureau of Abbvie, Aurania and Horizon Pharma, and receiving grant support from BMS. Blanco, Blazer, Bridges and Poll-Hunter report no relevant financial disclosures.
November 18, 2020
13 min read
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Meaningful measures: Diversifying rheumatology workforce starts with the pipeline

Issue: November 2020
Disclosures: Dowell reports being on the speakers' bureau of Abbvie, Aurania and Horizon Pharma, and receiving grant support from BMS. Blanco, Blazer, Bridges and Poll-Hunter report no relevant financial disclosures.
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With the election of Barack Obama as president or the nomination of Kamala Harris as vice president, some might consider the matter of equal opportunity for non-white people in the United States closed for discussion. Yet, the struggle to eliminate social inequality persists.

Despite considerable social progress, barriers remain to prevent Black, Latino and Native American individuals from rising to positions of prominence, wealth or financial security. As such, these populations are also significantly underrepresented as physicians across several medical specialties, including rheumatology.

Source: Adobe Stock.
Source: Adobe Stock.

“This is such a layered problem that is so rooted in the structural racism in the United States,” Ashira Blazer, MD, assistant professor of rheumatology at NYU Langone Health, told Healio Rheumatology. “We talk a lot about getting Black and brown people into rheumatology, but the pipelines are very sparse.”

When experts like Blazer discuss those pipelines that feed medical schools, they spend considerable time talking about setting children on course from the time they are learning their ABCs. “In New York, there are elite kindergartens that are incredibly competitive, and I do not have to tell you that these schools are largely attended by white children,” she said.

From that point, at every step along the way — middle school, high school, college, medical school, internship, residency and fellowship — mechanisms ranging from biased standardized testing to socioeconomic disparities hamstring non-white students in pursuit of higher education.

This brings the discussion to rheumatology-specific issues. “Rheumatology is actually interesting because there are workforce issues to begin with,” Irene Blanco, MD, MS, associate dean of diversity enhancement and rheumatology fellowship program director at Albert Einstein College of Medicine, said in an interview.

Because rheumatology is a such a small specialty, medical school students and residents get little exposure to it through rotations or courses. “If you can’t see it, you can’t be it,” Blanco said.

 Source: NYU Langone Medical Center.
Providing medical students with diverse topics and speakers from diverse backgrounds during Grand Rounds can go a long way to fostering interest in rheumatology, noted Ashira Blazer, MD. “Students can see themselves represented in the speaker and hear about issues that they care about. This can raise interest in rheumatology, showing how the specialty is relevant for their lives.”

Source: NYU Langone Medical Center.

These compounding factors result in an uphill battle in channeling an adequate number of non-white individuals who make it through medical school into a specialty that already has trouble attracting qualified, capable people in the first place.

But despite these challenges, the experts who spoke to Healio Rheumatology offered solutions, if not hope. They spoke of existing programs that are geared toward exposing young children to math and science and exposing medical students to rheumatology. They discussed ways to build trust in racially discordant provider-patient relationships.

In addition, they encouraged rheumatologists not only to give back to their communities and their alma maters, but also to provide a sales pitch for their field. Finally, they spoke candidly about this particular moment in time — woke culture, Black Lives Matter and other associated protest movements — and how it may forge a more diverse rheumatology workforce in the future.

Numbers Don’t Lie

Data from the Association of American Medical Colleges (AAMC) show that while 13.4% of the general population is Black, just 5% of physicians in the U.S. are Black. Similarly, Latino or Hispanic physicians comprise just shy of 6% of the physician workforce despite accounting for 18.4% of the U.S. population. Moreover, Native American or Alaska Native individuals make up 1.3% of the overall population but just 0.3% of physicians.

With these numbers in mind, Norma Poll-Hunter, PhD, senior director of the Human Capital Initiatives in Diversity Policy and Programs at the AAMC, addressed the question of what, exactly, constitutes equitable representation in the medical workforce. “We have moved away from the idea of population parity, where, for example, if the population is 13% Black, then 13% of physicians should also be Black,” she said.

Norma Poll-Hunter, PhD
Norma Poll-Hunter

The trend has been to look at the idea of diversity holistically. “We want to show that diversity in the medical workforce can benefit everyone,” Poll-Hunter said. “More diversity in medical schools can lead to exchange of cultural information and more open dialogue about race and ethnicity.”

Research shows that diverse classrooms contribute to “cognitive complexity,” which can lead to a host of benefits that transcend far beyond just equal representation in the classroom and the clinic, according to Poll-Hunter. The thinking is that if medical students are exposed to a more diverse group of classmates as they move through their education, they will emerge with greater understanding of the real-world populations they will ultimately serve.

S. Louis Bridges, Jr., MD, PhD
S. Louis Bridges, Jr.

S. Louis Bridges, Jr., MD, PhD, physician-in-chief and chair of the department of medicine at the Hospital for Special Surgery, and chief of the division of rheumatology at both HSS and New York-Presbyterian/Weill Cornell Medical Center, said this greater understanding can translate into improved patient outcomes. “Having a more diverse workforce leads to all patients being more honest about any cultural beliefs that might influence their adherence to medications or health recommendations,” he said. “They feel more part of shared decision-making with their providers.”

This is the kind of message Poll-Hunter hopes to spread in her work at AAMC. “We want to show people that diversity in the medical workforce is good for public health,” she said.

In a more perfect world, it would not be necessary to make these arguments for more non-white MDs, DOs and PhDs in clinics and hospitals across the country. But the world is far from perfect, and the obstacles to equal representation are many.

Starting at the Beginning

Diversifying the medical workforce begins long before medical school. Blazer described one major barrier that keeps underserved and underprivileged Black and brown children out of higher education. “What gets done in our schools is based on who has the time, money and know-how to bring resources into the system,” she said.

White parents often have more of all of the above and can therefore draw more attention to their children and the schools they attend. “For a number of reasons, Black and brown parents have a lack of agency in this country,” she said.

One issue is that these parents often have lower socioeconomic status and, accordingly, need to work multiple jobs just to make ends meet. There is little time for advocacy.

“The other part of it is that Black and brown parents often do not have the background and the self-efficacy to believe, No. 1, that they have something worthwhile to say, and, No. 2, that someone on the other end is going to listen and act,” Blazer said. “Of course, on an individual basis, anyone can do anything. But on a societal level, the trend is that minorities do not have the kind of advocacy tools that white parents do.”

Another issue is access to information about navigating the finances and bureaucracy of higher education, according to Poll-Hunter. “These structural barriers can become real barriers in someone’s mind and force them to essentially eliminate certain possibilities, like attending college or medical school, from their reality,” she said.

Once a student has made it to college, the next step is to show them what a career in medicine looks like. “There are programs to help students learn what courses they need to take, there is clinical shadowing, and we can connect young people with mentors who will guide them along the way,” Poll-Hunter said.

The Robert Wood Johnson Foundation funds the Summer Health Professions Education Program. Such educational programs support students who are underrepresented in the health professions, including Black, Latino, Hispanic, American Indian and Alaska Native students, and students who are economically disadvantaged, according to Poll-Hunter. “There are close to 9,000 individuals who have participated in the program who have become physicians,” she said.

The message in this data point is clear: “We know these programs work,” Poll-Hunter said. “We get them excited about a career in medicine, then we expose them to it, then we give them the practical tools to achieve it.”

Bridges offered further perspective on shepherding non-white students up the ladder. “It has been recommended that medical schools put less emphasis on MCAT scores and GPA during the admissions process,” he said.

A companion approach would be to place less emphasis on board scores of applicants for residency and fellowship training slots. “Compassion, work ethic, empathy, commitment to service, perseverance and resiliency may be more highly considered,” Bridges said. “Fellowship and division directors should advocate for being more intentional in hiring non-white applicants.”

Targeted marketing of opportunities to medical residencies with a larger number of non-white trainees is another solution Bridges offered. “We need to change the way we relate to trainees and avoid stereotypes, as well as not tolerating racially or culturally insensitive behavior,” he said.

Some of these approaches are already being put into action. “The National Academy of Medicine has advocated for policy changes to give greater support to historically African American medical schools and Hispanic-serving institutions, as well as more direct support to minority physicians during their training,” Bridges said. “Academic institutions that train future rheumatologists must truly value minority faculty and trainees. This can be done by treating them as assets to the institution and avoiding isolation or disenfranchisement.”

Importance of Salesmanship

With programs in place to foster Black and brown college graduates into medical school, selling them on a career in rheumatology presents a whole new set of hurdles.

Sharon Dowell, MBBS
Sharon Dowell

Sharon Dowell, MBBS, associate professor of medicine at Howard University, suggested that the personal is as important as the regulatory in exciting young medical students to enter the field. “There is one rheumatologist in the one main hospital in Barbados, where I am from,” she said. “She gave great presentations, and it was intriguing and exciting to work with her. This is why I became interested in rheumatology in the first place.”

This type of salesmanship can play out on a larger scale, according to Blazer. “One of the things we can do is have more visibility for physicians and educators of color in our community,” she said.

To that point, Blazer said that NYU Langone has been much more intentional about inviting speakers of various backgrounds to deliver Grand Rounds and other such lectures. “We are also trying to diversify the topics we discuss in these conferences,” she said.

The benefit of this approach is clear, Blazer said. “Students who come to see these rounds can see themselves represented in the speaker and hear about issues that they care about,” she said. “This can raise interest in rheumatology, showing how the specialty is relevant for their lives.”

“At the heart of it, what young people are looking for is a path that will give them happiness and satisfaction, along with a source of income,” Dowell added. “They need to see rheumatology as something they can see themselves doing.”

Irene Blanco, MD, MS
Irene Blanco

Blanco underscored this point. “There is some evidence showing that the more exposure you have to a specialty early in your training, the more likely you are to enter that field,” she said. “When you are not exposed, it is difficult to understand how it may fit your life.”

For Dowell, closing out the sales pitch with a deep dive into the particulars of the specialty can pay dividends. “When we describe rheumatology only in terms of treating arthritis, it minimizes all that we really do,” she said. “It is so much more than that, and as a specialty, we have not done a good job of explaining our field — the diversity of the diseases and the long-term relationships we form with our patients — and how it can be both rewarding and exciting.”

A Matter of Trust

The experts who spoke to Healio Rheumatology were careful not to make all of this sound too easy. Exposing marginalized children to science and ensuring that a charismatic rheumatologist will pilot them into the specialty is a tall order.

In fact, racial diversity issues in the rheumatology workforce are bigger than rheumatology, bigger than medicine itself, and manifest on both sides of the doctor-patient relationship.

Blanco spoke candidly about the obstacles facing African American populations in the U.S. — namely, how the legacies of slavery and Jim Crow impact the lives of Black Americans every day, even when they go to the doctor.

She noted that the Tuskegee syphilis experiment — in which the U.S. government intentionally failed to treat Black men to observe the natural course of the disease and failed to tell these patients they were doing so — ended in 1972. “Black men in this country have significant communication and trust issues in the public health sphere,” she said. “Data from other specialties have shown, for example, that black men have better outcomes if they have a racially concordant primary care physician.”

Given the shortage of rheumatologists and the fact that more than half of rheumatology practitioners are white, the likelihood that Black patients will be treated by a Black doctor is low.

“This is not to say that a racially or ethnically discordant doctor-patient relationship can’t work,” Blanco said. “From a doctor’s perspective, it is important to be more sensitive, to try to be a partner to your patients and leave the paternalism aside.”

Blazer offered further thoughts on ways to ensure that non-white patients can get the care they need, regardless of the race or ethnicity of the physician. “We actually have a diverse health care force,” she said, noting that non-white practitioners have frequent patient contact as nurses, assistants, phlebotomists and physical therapists, to name a few. “There is huge potential to create innovative models of care that can have a number of benefits.”

In addition to building trust, another benefit of this model is to off-load some of the responsibility from overworked rheumatologists. “Using assistants to handle billing questions and deal with insurance companies can improve patient access to medications, as well,” Blazer added.

Understanding and improving on the way Black patients interact with the health care system overall is just part of the puzzle. It is also important to understand that those trust issues can be found across the racial and ethnic spectrum.

Beyond Black and White

For groups of Latino and Hispanic descent, generations of anti-immigrant sentiment and legislation have yielded similar results as Jim Crow. An additional component is that Latino and Hispanic populations, like Black populations, are not a monolith.

“Think about the diversity of the Latino and Hispanic communities in the U.S.,” Blanco said. “Each group has a different immigration history, which plays directly into how that group may or may not access quality education, and the types of bias and discrimination they may face.”

For example, Poll-Hunter pointed out that because individuals from Puerto Rico are U.S. citizens, they may have access to resources that an immigrant from Mexico or Nicaragua may not. But these issues are just the tip of the iceberg.

“Right now, today, we are seeing forced sterilization of women in immigration camps,” Blanco said.

For Poll-Hunter, hearing such news can do irreparable damage in a host of ways. One of them is that Latino and Hispanic populations may lose trust in the American health care system.

Another is to make Latino and Hispanic citizens feel excluded from the possibility of “reaching the American dream,” which may encompass rising to medical school or becoming a rheumatologist. “The message we are sending is that they are excluded from the opportunity to reach their highest potential,” Poll-Hunter said.

The situation is even more dire for American Indians and other indigenous communities, according to Poll-Hunter. “They are essentially invisible,” she said. “They are forgotten.”

Poll-Hunter believes that understanding of tribal communities — the relationships tribes may have with the U.S. government, for example — is unfamiliar to many Americans. “We need to dispel basic stereotypes and myths to fully engage these communities,” she said. “Then it is important to partner with American Indian and other indigenous communities and to facilitate relationships with tribal colleges and universities to increase representation in the medical community.”

Big Problems, Big Solutions

It may be a long time before outreach programs bear fruit, with those children finding their way from elite kindergartens to rheumatology. In the meantime, there are millions of Black and brown patients that require culturally competent care.

Bridges said that the American College of Rheumatology has recently formed a Diversity and Inclusion Task Force. The group has 11 members that will help to set a national agenda for addressing these issues in the subspecialty. “I believe that the rheumatology community is invested in this journey and I look forward to making a significant impact in this area,” he said.

If there is another statistic worth considering, it is that individuals of Asian descent comprise just under 6% of the U.S. population but more than 15% of medical school graduates. “It might be useful to figure out how Asian populations reached those levels,” Dowell said.

But even this could prove difficult to unpack. “One thing to consider is that the definition of what constitutes Asian in the U.S. population is broad,” Dowell said. The obvious cultural differences between Chinese, Japanese or Filipino Americans are as stark as those between people of Indian, Thai or Malaysian ethnicity.

For Dowell, the answer might lie less in what has gone right for Asian American populations than in what has gone wrong for African Americans. “Black struggles have been longer,” she said.

Nevertheless, examining which Asian American populations are most likely to reach the MD and PhD level may hold clues to helping other groups.

Capitalizing on the Moment

When asked if the current moment of protest could move the needle in terms of a more diverse rheumatology workforce, Dowell was optimistic. “This is an exciting time for change to happen,” she said. “We are so hopeful to see real and sustainable change to emerge, because we are seeing that it is not just Black people that are advocating for Black lives.”

For Bridges, it is critical to take this momentum and act. “There needs to be a sustained national plan to improve, with frequent adjustments and additional investments as needed along the way,” he said. “This effort requires resources that should be provided to make this a priority.”

Overall, Blazer is encouraged by the progress being made with such efforts. “Some of it is performative, but some of it real,” she said. “We just have to remember that the ultimate goal is to improve outcomes for our patients.”

For Poll-Hunter, a more equitable work force and health care system absolutely will lead to improved patient outcomes. With that in mind, she is encouraged by the protest movements happening around the country. “For those of us who do diversity and inclusion work, this moment has given us extra wind in our sails,” she said.

But as a parting shot, Poll-Hunter warned that the attention given to these issues should not be temporary. “These issues are going to take time to change,” she said. “This is a marathon, not a sprint, and we will need multiple partners along the way.”